NJ FamilyCare/Medicaid. Your Guide for Making Medicaid Managed Care Work for You

Transcription

1 NJ FamilyCare/Medicaid Your Guide for Making Medicaid Managed Care Work for You

2 NJ FamilyCare/Medicaid Your Guide for Making Medicaid Managed Care Work for You Developed by: The Elizabeth M. Boggs Center on Developmental Disabilities UMDNJ-Robert Wood Johnson Medical School A University Center for Excellence in Developmental Disabilities Education, Research, and Service and The State of New Jersey, Department of Human Services Division of Medical Assistance and Health Services If you would like more copies of this guidebook, or copies in Spanish, call This guidebook is also available on the web in English and Spanish at: First printed in January The second printing in July 2011 was funded by the New Jersey Department of Human Services, Division of Developmental Disabilities Contract 07ML11C.

3 The Purpose of This Guidebook Medicaid provides government funded health coverage for children and adults who do not have much money and who have a disability. Medicaid eligibility for people with disabilities is based on an assessment of both disability and financial resources. People who are on SSI (Supplemental Security Income) receive Medicaid as part of their SSI eligibility. All over the country, people are getting their health care through managed care. In New Jersey, people who receive NJ Family Care/ Medicaid will receive their health care through managed care. Managed care is another way for you to get your health care. In managed care, you will be able to find doctors who will provide you with routine, preventative, and specialty care. Managed care coordinates care between your doctors and other health providers. If you are a client of the NJ Division of Developmental Disabilities, your Health Maintenance Organization (HMO) will assign you a care manager to help in getting the services you need. If you were on Medicaid before receiving your benefits through managed care, you have not lost any of your benefits. Your Medicaid services will now be provided by an HMO. This guidebook explains managed health care in New Jersey. By going over this guidebook by yourself or with a family member, friend, or other helper, you can learn more about how managed care works. This information will help you get the health care you need as well as help you keep track of important information about your doctors and health care services. Note: Words that are underlined are explained in the glossary at the back of this guidebook.

4 What is in This Guidebook? This guidebook has four chapters. We hope you will read the whole guidebook but you can also look things up in the different chapters. Chapter 1: Chapter 2: Chapter 3: Chapter 4: What is Managed Care and How Does it Work? Page 31 How to Use Managed Care Page 19 Tips on Improving Your Health Care and Being Healthy Page 31 What You Can Do If You Have Problems and Concerns About Your Doctor, Your Health Care or Your HMO Page 41 Glossary Page 47 My Important Information Page 49 Sources of Help Inside Back Cover

5 Chapter 1 What is Managed Care and How Does It Work? NJ FamilyCare/Medicaid You receive your health care through a Health Maintenance Organization, called an HMO for short. As a member of an HMO: You have access to health care 24 hours a day, 7 days per week. You have a Primary Care Provider, also called a PCP. The Primary Care Provider is your regular doctor or nurse practitioner. Your Primary Care Provider keeps track of all of your health care needs. To see a specialist, you may need permission from your PCP. This permission is called a referral. You will need to follow HMO policies about referrals to receive care from specialists. Check with your HMO to find out how their referral process works. Generally, you will need to use the health care providers in the HMOʼs provider network. A network is a group of doctors, hospitals, pharmacies, labs, and other providers who have agreements with your HMO to provide your health care. Chapter 1 PCPs Specialists Labs X-Ray Eye & Ear Care DME Pharmacies Dentists Hospitals 1

6 How Is Managed Care Different? Before Before managed care, the Medicaid program was called fee-for-service. Chapter 1Your Guide for Making Medicaid Managed Care Work for You Under fee-for-service, a person could go to any doctor or hospital that accepted Medicaid. Often it was hard for people to find health providers who would accept Medicaid and treat them. Many people did not have a regular doctor to take care of all of their health care. Another problem many people faced was that they could not get health care on evenings, during the night or weekends when necessary. 2 Now The managed care program provides services that actively link you to all needed medical and other health care services. This link helps you to get the care you need and keeps track of your needs and health services. This is called coordinated care. Since you belong to an HMO, you will not have to search to find health care providers. This is the role of the Primary Care Provider and Health Maintenance Organization. Your HMO has to provide health care coverage for you 24 hours a day, 7 days a week. If you get sick late at night, you can call your PCP or the HMOʼs 24-hour number. You will no longer need to go to the emergency room for health care unless you have a true medical emergency. See page 27 for examples of true emergencies. One of the best things about managed care is that HMOs want to keep you healthy. HMOs not only treat illnesses but also work to prevent health problems. They like people to get regular checkups and immunizations. Some HMOs even offer programs to help you stop smoking.

7 Keep Track of Your Enrollment Information It is a good idea to have your HMO information and numbers to call all in one place. Use this form to keep your information together. Chapter 1 Date I enrolled in NJ FamilyCare/Medicaid: Name of HMO: HMO 24 hour phone number: My HMO membership number: My Medicaid ID number: Name of my Primary Care Provider: Phone number of my Primary Care Provider: Name of my HMO care manager: Phone number of my HMO care manager: Phone number of the Health Benefits Coordinator TTY number of Health Benefits Coordinator

8 You should know that if you are not satisfied with your HMO or PCP, you can change after you enroll. If you want to change your HMO: You can change your HMO in the first 90 days of enrollment and then annually thereafter in the open enrollment period. Chapter 1Your Guide for Making Medicaid Managed Care Work for You You can change to a different HMO for good cause if you are not satisfied with your HMO or during the annual open enrollment period from October 1 to November 15. Call the Health Benefits Coordinator if you need to change your HMO. Call or TTY If you want to change your PCP: You may change to a different Primary Care Provider within your HMO if you are not satisfied with your Primary Care Provider. Call your HMO if you need to change your PCP. The Health Benefits Coordinator is also available to help you solve problems with your HMO. Chapter 4 tells you some things you can try to make things work better before you actually make a change. 4

9 Benefits in Managed Care Through your HMO you are able to get all of the same services you got under Medicaid before. In NJ FamilyCare/Medicaid you might get these services in a different way or from different health providers. You will get most of the services under your HMO. You may get other services through fee-for-service Medicaid. Your Primary Care Provider will help you get the services you need. Your care manager in the HMO, if you have one, will also help you get the services you need. The benefits and services you can get will be listed in your HMO Member Handbook. Chapter 1 5

10 NJ FamilyCare/Medicaid Plans A, B, C This is a list of services that will be provided to you in managed care under NJ FamilyCare/Medicaid, Plans A, B, C when they are medically necessary. Chapter 1Your Guide for Making Medicaid Managed Care Work for You 6 Primary health care doctor or nurse visits Preventative health care and counseling Specialist doctor visits Laboratory tests and X-ray services Prescription drugs program services for children Family planning services and supplies Chiropractor services Podiatrist services Hearing and hearing aid services Home health agency care Medical supplies Prosthetics and Orthotics Dental services Emergency ground transportation Organ transplants Nursing Facility Rehabilitation Hospital in-patient stays and out-patient services Emergency medical care 24 hours per day Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Eye care and eye care appliances (such as eyeglasses) Durable Medical Equipment (such as wheelchairs) Personal Care Assistant Services (not covered for Plans B and C) Outpatient Rehabilitation Therapy (includes physical, occupational, and speech pathology services; limitations for Plans B and C) Adult and Pediatric Medical Day Care (not covered for Plans B and C) Nursing Facility services for the first 30 days for Plan A Mental health and substance abuse services for people who are clients of the Division of Developmental Disabilities (DDD). (For people who are not clients of DDD, mental health care will be provided by fee-for-service Medicaid.) Hospice agency services

11 This is a list of services that will be provided to you through the fee-for-service program*. Non-emergency medical transportation through LogistiCare Family planning (when given by a non-hmo provider) Nursing facility care Abortions and related services of the Division of Developmental Disabilities (DDD) Nursing Facility care for Plan A beyond 30 days Mental health and substance abuse services for people who are not clients Write down the health care services that you use: Note: *For NJ FamilyCare Plans B and C, certain limitations and exclusions apply. Check your member handbook for details. Chapter 1 7

12 NJ FamilyCare Plan D This is a list of services that will be provided to you in managed care under NJ FamilyCare, Plan D, when they are medically necessary. Primary health care doctor and nurse visits Emergency room services Home Health Care services Hospice services Inpatient and outpatient services Laboratory services Radiology services Optometrist services Optical appliances Organ transplant services Prescription drugs Dental services for children under age 19 illnesses and injuries (limitations apply)* Prosthetic appliances (limitations apply)* only Maternity and related newborn care Diabetic supplies and equipment Chapter 1Your Guide for Making Medicaid Managed Care Work for You Family Planning services with network providers Physical, occupational, speech therapy for non-chronic conditions and cute Podiatrist services (excludes routine hygienic care of the feet) Private duty nursing when authorized by the HMO Transportation services limited to ambulance for medical emergency Well child care including immunizations, lead screening, and treatments Hearing and Hearing aid services for children under age 16 8

13 This is a list of services that will be provided to you through the fee-for-service program*. Abortion services Inpatient hospital services for mental health, including psychiatric hospitals, limited to 35 days per year Outpatient benefits for short-term, outpatient evaluative and crisis intervention, or home health mental health services, limited to 20 visits per year (when authorized by the Division of Medical Assistance and Health Services) Inpatient and outpatient services for substance abuse are limited to detoxification Write down the health care services that you use: Chapter 1 Note: *Certain limitations and exclusions apply. Check your member handbook for details. 9

14 Services for the Aged, People with Disabilities, Chronic Conditions, and other Special Health Care Needs Chapter 1Your Guide for Making Medicaid Managed Care Work for You 10 The Division of Medical Assistance and Health Services requires that HMOs provide specific services to help people with disabilities and other special health care needs get health care for their conditions. When we refer to people with disabilities and special health care needs, we mean: Adults with physical, cognitive, developmental disabilities or chronic health conditions, and people who are aged. Children with chronic health conditions, physical disabilities, developmental disabilities, behavioral and/or emotional problems. NJ FamilyCare/Medicaid makes certain that your special health care needs will be met through managed care. Some of the ways include: Care management services Specialist as Primary Care Provider (PCP) Standing referrals Specialty services (including dental services) Durable Medical Equipment (DME) Americans with Disabilities Act compliance and accessibility Special programs for people who are aged Standards to ensure access to quality services

15 Care Management Care management links all needed medical and other health care services for people with special health care needs, including people with disabilities, and other chronic conditions. If you are a DDD client, you will be automatically assigned a care manager when you enroll. The HMO care management departments are available to help you to arrange your health care. Call the member services number on your HMO card and ask to speak with a care manager. Your care manager will be a nurse or social worker who will help you get the health services you need from the HMO. Your care manager will: Do an assessment to better understand your health care needs. Develop an Individual Health Care Plan with you to identify the services you will use. Provide help with referrals to specialty doctors and other services. Help to coordinate your health care services with other services you use, such as early intervention. Chapter 1 11

16 Specialist as Primary Care Provider NJ FamilyCare/Medicaid does allow specialists to be Primary Care Providers. This might be very important to you if you see a specialist for most of your health care. Chapter 1Your Guide for Making Medicaid Managed Care Work for You If you would like to choose your specialist as your PCP: You should have an existing doctor/patient relationship. The doctor must be able to provide all primary care services, including physical exams, preventive health care, immunizations, and treatment of general illnesses and injuries. The doctor must agree to serve as your PCP. The HMO will tell you how that will work. If your specialist cannot be your PCP, the HMO will work with you on making other arrangements to see the specialist. 12

17 Standing Referrals Referrals are a very important part of getting complete care. In managed care, you may need to have approval from your PCP to see most specialists and to get services from any other health provider. This approval is called a referral. If you have an ongoing health condition, your PCP may be able to give you a standing referral. This permits you to see a specialist for a certain number of visits or a time period. An example of a standing referral would be: or A referral that lets you see a neurologist 3 times A referral that lets you see a neurologist once a month for 6 months Chapter 1 13

18 Specialty Services HMOs are required to have specialists and specialty services to care for people with disabilities and special health care needs. HMOs may have clinics for disabilities like Spina Bifida, Cerebral Palsy, or Spinal Cord Injury. Chapter 1Your Guide for Making Medicaid Managed Care Work for You HMOs have doctors who treat people with health problems such as diabetes, cancer, heart and lung diseases. HMOs have a dental provider network, including primary and specialty care dentists, that will provide you with the special dental care that you need. However, if the HMO does not have the doctors that you need, the HMO will send you to other doctors outside the provider network. A provider network is a group of doctors, dentists, hospitals, pharmacies, labs, and other providers who have agreed to provide your health care under contract with your particular HMO. If you need specialty services due to your disability or health condition, talk to your PCP or care manager. 14

19 Durable Medical Equipment Durable Medical Equipment, DME for short, are items kept for a long time to help a person with a temporary or permanent disability or a person who is aged to stay healthy or be more independent. Wheelchairs and walkers are examples of DME. DME must be prescribed by your PCP or specialist. If you need DME: Find out what your HMOʼs rules are for getting DME and keeping it maintained. Find out who the DME providers are for your HMO. Work with your doctor and your care manager to get the DME you need. Chapter 1 15

20 Americans with Disabilities Act Compliance/Accessibility for People with Disabilities The health care providers in your HMO must provide access to people with disabilities, as required by the Americans with Disabilities Act (ADA). Chapter 1Your Guide for Making Medicaid Managed Care Work for You This means that the office either needs to be accessible or health services are provided in an accessible location. The kind of accommodations for physical access include: Use of a ramp into the PCPʼs office Easy entry into the bathroom Easy entry into the exam room If you need physical accessibility, ask the doctorʼs office about the accessibility of the office and exam rooms. Your care manager at the HMO can help you to find accessible services. For Individuals Who are Deaf or Hard of Hearing The HMOs and providers in their network must also provide interpreter services for people who are deaf or hard of hearing. For Individuals Who are Blind or Visually Impaired If you are blind or visually impaired, you can get a copy of the HMOʼs member handbook and other important information in alternate formats, such as Braille. 16

21 Special Programs for People Who are Aged Here are some important benefits in NJ FamilyCare/Medicaid for people who are elderly: Immunizations to prevent pneumonia, the flu, and other chronic conditions Screenings: Breast and Prostate Abuse and Neglect: Identification, Treatment, Prevention, and Awareness Special programs for people with congestive heart failure, chronic obstructive lung disease (COPD), diabetes, hypertension, and depression Special programs for people with cognitive impairments In addition to the other benefits in NJ FamilyCare/Medicaid, the following services explained on pages 5-13, are available to you: Care Management Specialist as your PCP Specialty services Chapter 1 17

22 Standards to Ensure Access to Quality Services NJ FamilyCare/Medicaid sets standards that must be followed by all HMOs to ensure the quality of services. Chapter 1Your Guide for Making Medicaid Managed Care Work for You These standards can be found in the contract between the State of New Jersey and the HMOs. Medicaid s Medicaid Office of Quality Assurance (OQA) monitors compliance of the HMOs with the standards in the NJ Medicaid Managed Care Contract to assure quality of care given, access to care, and adequate provider networks. If you are interested, you can find the New Jersey Medicaid Managed Care contract on the Department of Human Services Website at: 18

23 Chapter 2 How to Use Managed Care Managed care works best when you understand how to get good care. You can make it easier to get good health care by being a well-informed consumer. Here are some important things to know about your HMO membership card and your Health Benefits Identification Card To get health care through your HMO you will have 2 important cards: An HMO membership card A plastic Health Benefits Identification Card When you enroll in an HMO, you will get a membership card and a member handbook. Chapter 2 This is an example of an HMO membership card. Your card will have the name of the HMO, your name, and health care provider information. HMO MEMBERSHIP CARD NAME ID# DOCTOR PHONE # DENTIST PHONE # EFFECTIVE ISSUE NOT TRANSFERABLE FRONT HMO 800 TELEPHONE NUMBER WHAT TO DO IN AN EMERGENCY BACK 19

24 This is an example of a Health Benefits Identification Card. Your card will have your name and HMO printed on it. Chapter 2 IMPORTANT! Whenever you have a health care appointment, you will need to bring both your HMO membership card and Health Benefits Identification Card. Find a safe place to keep your cards. To help me remember to bring both cards to appointments I will Your HMO may also give you a different card for prescription drugs. If you have a prescription card, you need to take it with you when you go to the pharmacy. 20

25 Primary Care Providers and Specialists Being a member of an HMO means that you generally will need to use the health care providers in the HMOʼs network. Your PCP, along with your care manager, works to coordinate all of your health care so it fits together to meet your needs. In NJ FamilyCare/Medicaid, your Primary Care Provider could be one of the kinds of doctors or nurse practitioners listed below. Chapter 2 There are Different Kinds of Primary Care Providers Primary Care Providers can be doctors or nurse practitioners. Nurse practitioners are nurses with advanced training. Pediatricians (doctors) and Pediatric Nurse Practitioners provide health care to babies, children, and teenagers. Internists (doctors) provide health care to adults. Family Physicians (doctors) and Family Nurse Practitioners provide health care to people of any age. Often they take care of all of the members of a family. Some of the health care services your PCP and care manager will coordinate for you are: Physical exams Referrals to specialists and other health services Health services that prevent illnesses Hospital services Emergency room services 21

26 There are Different Kinds of Specialists Specialists are doctors who specialize in treating a system of the body or particular conditions. Chapter 2 Here are some examples of specialists: A Cardiologist is a specialist who treats the heart and circulatory system. A Neurologist treats diseases of the nervous system, such as seizure disorders An Orthopedist or orthopedic surgeon treats conditions of the bones and may assist patients with rehabilitation and specialized equipment 22

27 Referrals Remember that in managed care, you may need a referral from your PCP to see most specialists and to get services from any other health care provider. The referral will usually be a paper with: Your name and information about your health problem The name of the specialist you will visit The reason for the referral The number of visits approved to see the specialist Date Patient name and information Referral Form PCP name and information Chapter 2 Services to be Referred Number of visits Authorization number Diagnosis/Procedure Referred to Physician Specialist name and information You must bring the referral with you to the specialist. Sometimes the referral is sent by computer or faxed to the specialist. If you are not given a referral, you must check to make sure that one has been sent. It is your responsibility to bring the referral with you to the specialist. If you do not have the referral paper with you or one was not sent to the specialist, you probably will not be able to have the appointment. You will need to make another appointment. You may also need to bring other medical information with you to the specialist, such as X-rays or test results. In NJ FamilyCare/Medicaid, you may not need to get a referral to receive certain services. For example, women may go to an Obstetrician/Gynecologist for regular or routine visits without a referral. Check with your HMO on what options are available. For some services, such as certain diagnostic tests and surgery, you may also need permission from your HMO ahead of time. This is called prior-authorization. Your PCP will usually handle this. 23

28 Differences in How You Receive Some Services Under Medicaid Managed Care Chapter 2 In managed care, there are some differences in how you receive some services. You will get some of the services under the HMO and others through fee-for-service Medicaid. Mental Health Care and Substance Abuse Services: Mental health and substance abuse services are provided by your HMO if you are a client of the Division of Developmental Disabilities. You will use your HMO card for these services. Home Health Services Home health services are now provided by your HMO. 24

29 Types of Appointments In managed care, the type of appointments that the PCP gives to his or her patients are based on their health care needs. Routine Care Routine care is an office visit to see your PCP. You could be well, need care to prevent illness, need care to treat an illness, or the PCP could be watching your condition closely. Your PCP may provide these kinds of services at a routine care appointment: Annual gynecological exams for women Immunizations for children and adults Physical examinations Initial appointments Chapter 2 Your First Appointment with Your Primary Care Provider Call your PCP to make an appointment as soon as you can after you enroll. If you have not done so already, make a first appointment to see your PCP, also called an "initial" appointment. It is important for your PCP to get to know you before you have an illness. It is also important for you to get to know you PCP and his/her office. This first appointment is a chance to gather information, your health history, and to find out what your health is like. The first appointment is also a chance to begin to set some health goals. This is an important time to begin working with your PCP to get and stay healthier. 25

30 Urgent Care Urgent care is an office visit when you have symptoms that need immediate attention, but are not life threatening. Chapter 2 An urgent care visit might be necessary to treat conditions such as ear infections, the flu, or a sprained ankle. If you are sick or need medical advice, call your PCP. If you cannot reach your PCP, call your HMOʼs 24-hour number for help. Your HMO may direct you to another place to receive urgent care. Dental Care Dental services are a key part of your health benefits. If you have not yet chosen a dentist, please read the information in your Member Handbook on how to choose a dentist who is part of the HMO provider network. You can also call Member Services at your HMO. Once you have chosen your dentist, it is important that you get regular dental care. Regular dental care for both children and adults may prevent problems from occurring in the future. Your dentist will let you know how often you should see him or her for checkups. If you are having pain or other problems with your teeth, you should make an appointment right away. 26

31 Emergencies Your HMO provides you with health coverage 24 hours a day 7 days a week. That is an important way that managed care is different. Before managed care, some people may have gone to emergency rooms just to get routine health care. HMOs want people to use the emergency room for true medical emergencies only. A true medical emergency is a sudden or unexpected medical condition that threatens your life or limbs and which you believe requires quick medical treatment to prevent death or disability. Examples of an emergency include: Loss of consciousness Chest pain Seizures or convulsions Difficulty breathing Poisoning or drug overdose Severe bleeding Accidents involving severe injury Women in labor What to Do In an Emergency HMOs have rules to follow for emergencies. Your HMOʼs rules for emergency care are in your Member Handbook. Learn and follow your HMOʼs rules for emergency care. If you have questions about what to do in case of emergency, ask your PCP, your care manager, or member services at your HMO. Phone numbers to call are listed on your HMO Membership card. Chapter 2 If You Have Been Treated in the Emergency Room If you have had a medical emergency and have been treated in an emergency room, call your PCP to make sure he or she knows that. This will help you to get the follow up care that you need. Remember that one of the advantages of managed care is that you can call your PCP or the HMOʼs 24-hour number if you need help. 27

32 Chapter 2 Your Guide for Making Medicaid Managed Care Work for You Transportation Services If you need transportation to get to your PCP or other health services: Non-emergency Transportation You can arrange for non-emergency transportation services through the transportation broker, LogistiCare, by calling or TTY at least 2 business days before the scheduled appointment. Exception: Adult Day Health and Pediatric Medical Day Care transportation services are included in the payment to the providers. Transportation to Adult Health and Pediatric Medical Day Care are arranged through the provider. Emergency Transportation The HMO will only cover transportation services in the event of an emergency. This covers emergency ambulance ervices to an emergency room, and if necessary, the transfer to another hospital if the patient was not admitted to the first hospital. Language and Cultural Needs The Division of Medical Assistance and Health Services requires that the HMOs and the providers in their network provide 24- hour access to interpreter services for people who use languages other than English. Interpreter services can be provided by telephone language services or in-person interpreters. If you need an interpreter, translation of forms, or the member handbook, call member services at your HMO. 28

33 Understanding Health Coverage If You Have Both Private Health Insurance or Medicare and Medicaid Many individuals have private health insurance as their primary payer, as well as Medicaid fee-for-service (FFS) as their secondary payer. This includes people who have Medicare or belong to a Medicare Advantage HMO as their primary payer, as well as Medicaid FFS as their secondary payer. Medicaid HMOs will replace Medicaid FFS as the secondary payer when you enroll with the Medicaid HMO. Medicaid is always the payer of last resort. There are certain rules that may help you: 1) decide which providers to see, and 2) manage your out-of-pocket expenses, when you have primary and secondary coverage. 1. Which providers should I see? Guidance: Select providers in your private health plan or Medicare program as your primary provider network. If you are concerned about being billed for the balance, try to select providers who participate with both your primary payer and with the Medicaid HMO. Chapter 2 Chapter 2 The providers who accept payment from your private health plan are your primary provider network. When looking for a new provider, begin with the private health plan s provider list. Your provider will be paid by the private health plan first and then seek reimbursement for any outstanding balance from the Medicaid HMO. There is a benefit to finding a provider who is in both the private health plan and Medicaid HMO network: Medicaid and Medicare providers cannot bill you for the balance of a claim. If you see a provider who participates with your Medicaid HMO, and who is in the primary health plan s network or who accept Medicare, you are protected from balance billing. 29

34 Chapter 2 There is a benefit to finding a provider who is in the Medicaid HMO network, and not with the private health plan when: You have Medicaid benefits not covered by your private health plan, for example, dental or vision benefits. Services for these benefits would be covered by the Medicaid HMO. 2. How can I minimize my out-of-pocket expenses? Guidance: Use providers who participate with both your primary and secondary health plans whenever possible. After a provider with your private health plan bills that plan and gets paid, they will submit a claim for the unpaid balance to your Medicaid HMO. In the past, if the provider was not also a Medicaid provider, they may have been unable to bill Medicaid because they were not set up in the Medicaid FFS claims system. The Medicaid HMO can process claims of providers who are not in their claims system. At the same time, Medicaid FFS as well as the Medicaid HMOs cannot exceed the maximum reimbursement that Medicaid FFS would have covered if it had been the primary payer. EXAMPLE: If the provider bills the private health plan $100, and the private health plan reimburses 80% ($80), the $20 balance may go unpaid by Medicaid FFS and the Medicaid HMO because the $80 paid exceeds what Medicaid would have covered (e.g., $50) by $30. In this example, if the provider is not on the Medicaid HMO provider list, and does not accept Medicaid, they can bill you for the balance. If, however, the provider is a Medicaid HMO provider or Medicaid FFS provider, they cannot bill you for the balance. Medicare providers cannot balance bill as well. 30

35 Chapter 3 Tips on Improving Your Health Care and Being Healthy Managed care is complete and coordinated care. It is not only concerned about illness. It stresses getting and staying healthy. Managed care provides care for you when: You are sick You need preventative care Your disability or special health care condition needs treatment Working with Your Primary Care Provider Your PCP provides your health care in different ways, such as: Treating your illnesses Providing health screenings and immunizations Helping you get the other care you need by making referrals and getting approvals you need for other services Chapter 3 Your PCP also assists you to work on improving your health. Your PCP can be very helpful to you. Work with your PCP to improve your health. Write down the information about your PCP: My PCP is Address Phone number Office hours 31

36 Contacting Your PCP You should call your PCP when you: Are sick or hurt Need a check-up Need immunizations Need prescription drugs or a refill of a prescription Need a referral to see a specialist Need advice about health problems - Adapted from Community Service Society, 1998, Your health plan handbook. Chapter 3 Tips for Making Appointments Keep track of your appointments. Arrive on time. Make routine appointments in advance, at least two - three weeks ahead of time. Write them on a calendar or in a date book. Arrange transportation in advance through LogistiCare. Make sure you have directions to the appointment. Let the office staff know that you have arrived. Cancel your appointment if you cannot keep it. Do not let the time go to waste. It is also a good idea to make another appointment at the same time that you cancel the old one so you do not forget. 32

37 Communication is the Key to Good Health Care Communication is always important in health care. If you are having a health problem or problem with your health care, here are some important ways to communicate: Call Your Primary Care Providerʼs Office Tell the nurse or receptionist the problem you are having and that you need to see your PCP. He or she will give you an appointment to see your PCP. Be polite but firm to get the appointment you need. You can also ask for your PCP to call you if you think that the problem could be taken care of by phone. If you are choosing to wait for your PCP to call you, ask how long it will take for your PCP to return your call. Call Your Care Manager at the HMO Your care manager helps people with disabilities and special health care needs to get the services they need. Chapter 3 Call Member Services at the HMO If you are not sure who to call, you can call member services at the HMO. The phone number is on your HMO membership card. 33

38 Work as a Partner with Your Primary Care Provider to Improve Your Health Here are some things you can do to be an effective partner in your own health and health care: Be Prepared for Your Appointments Chapter 3 If you are having a health problem, keep track of it: How long have you had it? What are your symptoms? Is it getting better or worse? Know what medications you are taking - prescriptions as well as things you buy over the counter, like aspirin, antacids, or vitamins. Bring a list of medications with you when you go to see the PCP. If you canʼt bring a list, bring the bottles. Keep all medicines in the bottles they came in so they donʼt get mixed up. Bring a list of questions with you when you go to see the PCP. You might have questions like: How long will I have to take medication? How often do you want to see me for checkups? What else can I do to improve my health? 34

39 Follow Instructions and Take Notes Take medications as instructed. Follow recommendations for level of activity. If your PCP tells you to get extra rest or moderate exercise, follow those suggestions. Take notes if it helps you to remember things. Follow Up Follow through and get blood tests or other tests as prescribed. Make other appointments that your PCP thinks are necessary. If your PCP says to call and check in - do it. If you need a follow-up appointment - make it with the receptionist. Ask Questions If you do not understand instructions, ask to have them explained in a way that you can understand. If the PCP cannot explain, find out if there is a nurse or someone else in the office who can help explain. You can also take someone with you or call your HMO Care Manager to help you understand. If you do not understand the instructions for taking your medicine, check with your pharmacist. Pharmacists are trained to help people understand medicines and their possible side effects. Chapter 3 Let your PCP or HMO Care Manager know about major health changes and life changes. Life situations - both happy and stressful ones - affect our health. 35

40 Work on Getting Healthier Everyone can work on being as healthy as they can be, even if they have a disability or chronic condition. Chapter 3 People of all ages, children, and adults have needs for preventative care, such as: Exams and checkups Age appropriate screenings Immunizations Dental and vision exams Some common needs are: Women: gynecological exams, including pap smears and mammograms Men: All adults: prostate screening & exams blood pressure, cholesterol and other screenings All adults and children: regular dental care Children: well child exams including hearing & vision screenings, lead screenings, and screenings for orthopedic problems such as scoliosis Ask your PCP what your preventative care needs are based on your age, sex, personal history, and other conditions. 36

41 Tips for Staying Healthy Maintain a healthy weight. Eat a healthy diet. Get enough sleep. Exercise as much as you can. If you do not smoke do not start. If you smoke, get help in quitting. Your HMO may help you find a program to stop. Avoid illegal drugs and alcohol. Stay connected and involved with activities and other people. What are the things that you would like to work on to be healthier? Chapter 3 37

42 Keeping Track of Your Health Care To help you keep track of your doctors and other health providers, medications, and health visits, fill in the information on these 3 pages. My Health Providers Name of Specialty Address Phone doctor or Number provider Chapter 3 38

43 My Medications Name of Doctor who Date started Dose medicine prescribed it medicine Chapter 3 39

44 My Health Visits Date Doctor or Reason health provider for visit Chapter 3 40

45 Chapter 4 What To Do If You Have Problems or Concerns About Your Doctor, Your Health Care, or Your HMO In this guidebook, we have talked about how managed care should work. If you do have a problem or concern, we want you to know what you can do. In NJ FamilyCare/Medicaid, there are people to help you to get the health care that you need. There are also many ways to solve problems and concerns. Examples of Problems and Concerns Being refused care Not being able to get an appointment Not being able to schedule a physical exam Not being able to see a specialist Unhappy with the doctorʼs attitude Not being able to have access to someone who speaks your language Receiving medical care that does not seem to improve or maintain your health Not getting help when you call the HMOʼs Member Services number Being denied medically necessary equipment like wheelchairs Not being able to get physical accommodations at the doctorʼs office Not being able to see a specific doctor in a group practice Are you having problems with your health care now? Chapter 4 If these things do happen, there are steps you can take to make the situation better. 41

46 You Have Rights in Managed Care As a member of an HMO in New Jersey, you have important consumer rights. In New Jersey State Law, there is a New Jersey HMO Consumer Bill of Rights. Under this law you have: The right to information about your HMO and how it works The right to ask questions and to file complaints and appeals The right to appropriate treatment As a person who is in managed care through Medicaid, you have additional rights. The agreement that NJ FamilyCare/Medicaid has with the HMOs explains exactly what each HMO must do for members who have Medicaid. If your HMO is not giving you the medical services you feel you need, you have the right to a Medicaid Fair Hearing to state your case. Chapter 4 You Have Responsibilities in Managed Care As a person in an HMO, you have responsibilities that will help you get your best health care. You are responsible for: Providing all needed information to your doctors and nurses Seeking medical care when needed Following prescriptions and treatments Following the HMOʼs rules for getting health services Taking responsibility for being a partner in your own health care Asking questions to understand managed care Expressing your comments and opinions to your HMO so that they can serve you better 42

47 How You Can Get Help with Your Problems or Concerns Read your HMO member handbook for information about how to speak up about your concerns. Handling Problems or Concerns Within Your HMO Problems should be handled informally first. You can talk with your PCP, care manager, or HMO by phone. Steps to Take With Your Doctor 1. Discuss the problem with your doctor. 2. Give reasons why you disagree with a decision. 3. Try to come to a decision that works for you and your PCP. Steps to Take Within Your HMO 1. Call your care manager to discuss the problem. Your care manager may be able to talk to your doctor and HMO to figure out what should be done. 2. If your HMO denies you a particular medical service, you have the right to appeal that decision. If you want to appeal your HMO s decision to deny a service, you (or your health provider with your written permission) can request a Stage 1 appeal within the timeframe specified in your denial letter. To request a Stage 1 appeal, you can call or write to your HMO. You must follow your phone call with a letter. If you are currently receiving services that you want to continue during the appeal, you must request the continuation of benefits in writing to the HMO within 10 days of the date of your denial letter. Chapter 4 3. If your HMO reviews your Stage 1 appeal request, and you are not satisfied with that decision, you (or your health provider with your written permission) can request a Stage 2 appeal. You must request your Stage 2 appeal within 60 days of the denial letter. Again, you must follow your phone call with a letter. 43

48 Handling Your Problems and Concerns Outside Your HMO The best way to handle problems and concerns is to always try to work within the HMO to solve problems and concerns before seeking help outside of your HMO. In the case of urgent matters that require an immediate solution or the matter cannot be resolved within your HMO, this is what you can do: 1. If you are a Medicaid beneficiary, you have the right to a Medicaid Fair Hearing at any time. A written request for a Medicaid Fair Hearing must be made within 20 days of the date of the denial letter. Send the letter to: Fair Hearing PO Box 712 Trenton, NJ Remember that you do not need to go through the other steps first. Chapter 4 2. If you are still not satisfied with the HMO s decision after the Stage 2 appeal, you (or your health provider with your written permission) have the right to request a Stage 3 external appeal. To request a Stage 3 external appeal, you must complete some forms and send a filing fee of $2.00, payable by check or money order to the New Jersey Department of Banking and Insurance within 60 days of the timeframe in your denial letter. Send to: New Jersey Department of Banking and Insurance Consumer Protection Services PO Box 329 Trenton, NJ Medicaid beneficiaries can do this instead of - or in addition to - the Medicaid Fair Hearing. 44

49 What to Say When You Call Your HMO About a Problem or Concern You can use this sheet to make notes before you call your HMO. It helps you remember what to say on the phone. It is also good to have notes of what the person at the HMO told you. You might need your notes if you have a problem later. Date: Time: Your membership number: Phone number you called Name of person you spoke with: 1) Tell the HMO about the problem you are having. 2) Ask the HMO about what it will do to address the problem. 3) Ask the HMO how long it will take them to get back to you. 4) Ask who will get back to you. Chapter 4 - Adapted from the Community Service Society (Your health plan handbook.) Tip: Put a note on your calendar to remind you when you are supposed to get a response. If you donʼt hear from the HMO by that date, call back. 45

50 How to Write an Appeal Letter (Todayʼs date) Member Services Department (Name of HMO) (Address of HMO) Dear Sir or Madam: I am writing to formally file an appeal with (Name of HMO). I filed a complaint with the HMO on (Date), and did not agree with the response. My HMO membership number is. Chapter 4 (Explain your complaint here, along with the dates and the names of the people you spoke to. Also write why you did not agree with the answer to your complaint.) Thank you. Sincerely, (Sign your name) Tip: Remember to keep a copy of the letter. -Adapted from the Community Service Society (Your health plan handbook.) 46

51 Glossary Appeal - Process in a health plan for consumers or providers to use when there is disagreement about services, billing, or general procedures. Beneficiary - Person eligible to receive benefits under the Medicaid program. Benefits - List of health services that an HMO must provide to all its enrollees. Care Manager - Person who coordinates and monitors health services for a consumer. Client of the NJ Division of Developmental Disabilities - Person determined eligible to receive services from the NJ Division of Developmental Disabilities. Consumer - Person who uses benefits under an insurance plan. Durable Medical Equipment (DME) - Equipment needed by a patient that is used over time and not thrown away (wheelchairs, ventilators, braces, etc.) Emergency care - The immediate care that is necessary when a person has a condition, illness, or injury that is life-threatening or would significantly impair his/her health. Fair Hearing - Legal right of a Medicaid beneficiary if they have problems with their HMO or with the health care they receive through the HMO. Fee-for-service - The health care payment system under which physicians and other providers receive a payment for each service that they provide. These providers must be Medicaid and NJ FamilyCare Providers. Health Benefits Coordinator (HBC) - A person who helps people who receive Medicaid to enroll in HMOs. They receive and process enrollment forms, provide assistance locating PCPs, and answer questions about enrollment. Health Maintenance Organization (HMO) - A type of managed health care plan that provides, offers, or arranges for coverage of designated services needed by health plan members for a fixed, prepaid premium. Chapter 4 Managed Care - A system of health service delivery and payment that coordinates the use of health services by its members and provides a specific provider network. 47

52 Medicaid - Federal Program (Title XIX of the Social Security Act) that pays for health services for low income individuals including families with dependent children, senior citizens, people with disabilities, and pregnant women and children. Medicare - Federal Program (Title XVIII of the Social Security Act) that pays for most health services received by elderly, blind, or people with disabilities if they have made sufficient contributions to the Social Security System or receive benefits because their spouse or parents died. Medical Necessity - Term used to determine what services will be provided and for which payment will be made. This definition and how it is used varies from state to state for Medicaid beneficiaries. This definition is very important for people with disabilities. NJ FamilyCare - A program designed to meet the medical needs of uninsured adults and children through affordable health care coverage. Primary Care Provider (PCP) - Health provider who is responsible under managed care for the overall assessment and coordination of a patientʼs care. The primary care provider may refer patients to specialty health care or other health services. Provider Network - Physicians, nurses, hospitals, and other health providers under contract with a particular HMO. Chapter 4 Referral - Permission needed from the Primary Care Provider for a consumer to see a specialist or receive other health care services. A referral form signed by the PCP is commonly given to the consumer to bring to the specialist or other appointment. Specialist - Type of health care provider who specializes in a particular age group or type of conditions. Typically, under an HMO, a person needs a referral from their Primary Care Provider in order to see a specialist. Urgent Care - Occurs when the patient has an illness that is not life threatening but that requires immediate attention. 48